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Investigation of the prevalence, clinical features, and risk factors of dentin

hypersensitivity in a selected Brazilian population

Article in Clinical Oral Investigations · June 2013

DOI: 10.1007/s00784-013-1008-1 · Source: PubMed

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Clin Oral Invest
DOI 10.1007/s00784-013-1008-1

ORIGINAL ARTICLE

Investigation of the prevalence, clinical features, and risk

factors of dentin hypersensitivity in a selected Brazilian
population
Taís Scaramucci & Taciana Emília de Almeida Anfe &
Stella da Silva Ferreira & Antônio Carlos Frias &
Maria Angela Pita Sobral

Received: 29 June 2012 / Accepted: 24 May 2013

# Springer-Verlag Berlin Heidelberg 2013

Abstract four times a day, toothbrushing with excessive force, bruxism,

Objectives To evaluate the prevalence, clinical features, and and gastroesophageal reflux.
risk factors of dentin hypersensitivity (DH) in a Brazilian Clinical relevance DH was a common finding in this popu-
population. lation suggesting that preventive measures considering its
Materials and methods 300 patients at the Dentistry Clinic risk factors must be implemented in order to reduce or
of the University of São Paulo participated in this study. The control the symptoms.
subjects completed a questionnaire regarding their personal
information, the presence of DH, and some of its risk factors. Keywords Dentin hypersensitivity . Prevalence . Clinical
Following completion of the questionnaire, a clinical examina- features . Risk factors . Tooth wear . Non-carious cervical
tion was undertaken. To confirm the presence of DH, the sub- lesions
jects were evaluated with the use of a probe and cold air from a
triple syringe. Statistical analysis was performed with the chi-
square test and odds ratio, with the critical level p <0.05. Introduction
Results The prevalence of DH was 46 %. Females presented
a higher prevalence than males (p <0.05). The left posterior A non-carious cervical lesion is the loss of tooth structure at
region was affected by DH the most (maxilla=41 % and the cement–enamel junction, not related to caries [1]. This
mandible=36 %). Cold was reported as the most common event is of a multifactorial origin [2], where erosion, abra-
pain-inducing stimulus (88 %). The pain was described as sion, and abfraction are known to play important roles [3].
“discomfort” by 51 % of the subjects with DH. Toothbrush- Frequently, the non-carious cervical lesion is associated with
ing four times a day (p <0.05), toothbrushing with excessive DH, which is defined as a short, sharp pain that is originated
force (p <0.05), bruxism (p <0.05), and gastroesophageal from the exposed dentin in response to thermal, tactile,
reflux (p <0.05) were strongly correlated with DH. osmotic, chemical, or evaporative stimuli that cannot be
Conclusions The prevalence of DH was particularly high. attributed to any other form of dental disease or defect [4].
The risk factors for DH were gender (female), toothbrushing The epidemiological data about the prevalence of DH can
vary widely according to the population and the design of the
study [5]. In some studies, the prevalence of DH can be as
T. Scaramucci (*) : T. E. de Almeida Anfe : S. da Silva Ferreira : high as 74 % [6]; however, in other investigations, it appears
M. A. P. Sobral to be only about 4 % [7, 8]. The prevalence of DH may be
Department of Restorative Dentistry, School of Dentistry,
influenced by the population’s oral hygiene habits as well as
University of São Paulo, Av. Prof. Lineu Prestes 2227,
05508-900 São Paulo, SP, Brazil the consumption of acidic foods and drinks [5]. In addition, it
e-mail: [email protected] was observed that patients from a specific specialist practice,
such as periodontology, tend to show a higher prevalence of
A. C. Frias
DH (84 %) due to the greater risk of root exposure as a result
Department of Social Dentistry, School of Dentistry,
University of São Paulo, São Paulo, Av. Prof. Lineu Prestes 2227, of the loss of attachment and gingival recession [9]. In
05508-900 São Paulo, SP, Brazil relation to the study design, some studies are based only on
 Clin Oral Invest

a questionnaire [10–12], where subjects are asked to self- Sample size determination
report the presence of DH. Usually, the prevalence found in
these studies is high, as the 50–55 % reported by Gillam et al. The sample size determination was performed with the for-
[10] and Clayton et al. [11] and the 68.4 % reported by mula described in Naing and Rusli [23], considering a 95 %
Bamise et al. [12]. Other studies evaluated the self-reported level of confidence and a precision of 5 %. For the calcula-
DH as well as the DH that is diagnosed with a clinical exam tion, it was considered the 17 % prevalence of DH obtained
[5, 13–18]. The examination of the patients generally yields in the study of Fischer et al. [13], which was the only data
lower prevalence values (2.8–42.4 %). The overestimation of found for Brazilian population at the time of the elaboration
the magnitude of DH found in questionnaire-based investi- of the study design. According to the calculation, a sample
gations can be related to the patient’s difficulty in determin- size of 227 subjects would allow the determination of the
ing the cause of the pain that they are experiencing. In some population prevalence with a good precision.
cases, they may mistakenly attribute their pain to DH when
in fact it is caused by another dental disease, such as caries Data collection and oral examination
[5]. Moreover, according to Fischer et al. [13], epidemiolog-
ical studies should also investigate the relation of DH with its Data collection and oral examinations were conducted by
possible causative factors, such as dental erosion, in order to three investigators previously trained to diagnose DH (T.S.,
suggest the appropriate preventive measures for that specific T.E.A.A., and S.S.F.). The consistency among the investiga-
population. tors was tested prior to the beginning of the study through the
To the author’s knowledge, there are only a few reports evaluation of a small percentage of subjects, which were re-
about the prevalence of DH in Brazilian populations [13]. In evaluated in a second time by a different investigator. A
the last few decades, a change in the habits of people world- standard κ test was performed to evaluate this data, obtaining
wide has been observed with an increase in the consumption κ values in the range of 0.713–0.806, which represents a
of acid drinks [19] and a greater concern about oral hygiene substantial agreement.
[20]. These changes might have an impact in the prevalence A questionnaire regarding the personal information
of DH [20] and supports the current need for more recent (name, age, and gender), the presence of DH, its related
investigations. Thus, the aim of this study was to evaluate the factors (type of sensitivity, trigger stimuli, degree of pain,
prevalence, clinical features, and risk factors of DH in a location of the sensitive teeth, and treatment attempts), and
Brazilian population. The study was carried out at the Restor- its causative factors (frequency of toothbrushing, bristle
ative Dentistry Clinic of the School of Dentistry, University of hardness, use of excessive force during toothbrushing, daily
São Paulo. consumption of acidic foods and drinks, presence of gastro-
esophageal reflux, frequent vomiting, and bruxism) was read
to the subjects and the answers were recorded. The questions
Materials and methods about the characteristics of DH were asked only of the
subjects who reported having DH.
Ethical aspects and sample selection All subjects were submitted to a clinical exam, which was
performed on all teeth, except the third molars. In this exam,
The study protocol was approved by the local Ethics Com- the number of teeth, the presence of dental caries, and resto-
mittee in Research (School of Dentistry, University of São rations were also recorded. The teeth with any of the follow-
Paulo, process no. 163/08). This investigation was a cross- ing conditions were not included in the evaluation of DH:
section and single center study conducted at the Dental caries, root-filled, crowns, and abutment for dentures and
School Clinic of University of São Paulo. The aims of this bridge work [15].
investigation and all the procedures involved were explained The patients who reported having DH were submitted to a
to each subject, who had to sign a written informed consent specific DH evaluation, using tactile and cold-air stimula-
prior to the study. To be included in the study, subjects had to tion. The tactile stimulus was performed with a probe, which
be 18 years of age or older and in good health. The exclusion was applied with slight pressure perpendicular to the cervical
criteria were based on the studies of Clark and Troullous [21] region (buccal and lingual) of all the teeth in a mesial-distal
and Gillam et al. [22], and included the presence of any direction, in order to identify any sensitive area. If DH was
chronically debilitating disease or any chronic disease related detected, subjects had to rank their pain according to the
to daily pain episodes, such as arthritis; having periodontal following scale: 1—discomfort, 2—moderate pain, or
surgery, or scaling and root planning procedures less than 3—strong pain. Ten minutes after the tactile stimulus, the
6 months before the evaluation; non-collaborating patients; response of the subject to cold-air sensitivity was assessed
any disease requiring analgesic drugs, tranquilizers, or mood- using a dental air syringe applied perpendicular to the cervi-
altering medication; and the use of orthodontic appliances. cal region of the tooth, at a distance of approximately 1 cm
Clin Oral Invest

for a period of 3 s [16]. The surrounding teeth were isolated sensitive due to the air from the syringe. Thirty-seven subjects
during testing using the investigator’s fingers. Again, if DH with DH (27 %) had tried to treat this condition with the use of
was detected, patients were asked to rank their pain according desensitizing toothpastes. Fourteen subjects (10 %) opted for
to the previously described scale. another treatment alternative, such as fluoride, in-office prod-
After the evaluation, the subjects with hypersensitive ucts, and laser. The remaining 88 subjects with DH (63 %) had
teeth received instructions from the investigators in order to never tried any treatment for the condition.
minimize DH symptoms, such as substituting their regular Table 1 presents the DH distribution data according to
dentifrices for sensitivity dentifrices. Furthermore, they re- gender and age. Of the 139 subjects with DH, 100 were
ceived a clinical treatment for this condition using the product women and 39 were men, giving a female to male ratio of
Sensi Kill (DFL, Rio de Janeiro, RJ, Brazil). 2.66 (p <0.01). No association could be observed between
DH and any of the different age groups of the study. Regard-
Statistical analysis ing the frequency of toothbrushing (Fig. 1), 4 subjects with
DH (3 %) reported to brush their teeth only 1 time/day, 40
Frequency distribution and cross-tabulation tables were con- subjects (29 %) brushed 2 times/day, 73 subjects (52 %)
structed using the Epinfo 7TM Software (Center for Disease brushed 3 times/day, and 20 subjects (14 %) brushed 4
Control and Prevention, Atlanta, GA, USA). Associations times/day. Two subjects with DH (2 %) could not estimate
between discrete variables were tested by the odds ratio, how many times they brush their teeth a day. The subjects
considering a 95 % confidence interval, and by the chi- who brush their teeth four times a day had a significantly
square test, with a p value of <0.05 as significant. greater risk of DH. Seventy-one patients with DH (51 %)
stated that they use soft brushes for toothbrushing, 59
patients (42 %) use medium brushes, and only 8 subjects
Results (6 %) reported the use of hard brushes. One patient did not
know the type of brush that he/she uses. It was not possible to
Three hundred subjects were eligible to participate in this establish a relation between the hardness of different brush
study. The age of subjects ranged from 18 to 77 years old, bristles and the presence of DH (Fig 2). Of the subjects
with a mean age (±SD) of 40.42 years (±13.75). Of the 300 diagnosed with DH, 74 (53 %) admitted to brushing their
subjects, 179 (60 %) were females and 121 (40 %) were teeth applying excessive force, 56 (40 %) reported to have
males. The prevalence of DH was found to be 46 %, affect- bruxism, 34 (24 %) stated that they were diagnosed with
ing almost half of the subjects (139). The left side of the gastroesophageal reflux, and 5 (3 %) had frequent vomiting.
mouth was most frequently affected by DH (maxilla=41 % Figures 2 and 3 show that brush-applying excessive force,
and mandible=36 %). Cold was reported as the most com- bruxism, and gastroesophageal reflux were found to be risk
mon pain-inducing stimulus (88 %), followed by air (68 %), factors for DH, while no relation was found between DH and
toothbrushing (42 %), sweets (34 %), and heat (25 %). frequent vomiting, and between DH and the consumption of
Seventy-one subjects with DH (51 %) described their pain acidic foods and drinks (Figs. 3 and 4).
as just a discomfort, while 57 (41 %) stated that they experi-
enced moderate pain. Only 10 subjects (7 %) described their
pain as a strong. The 139 subjects with DH presented a total of Discussion
981 sensitive teeth, with an average of 7 sensitive teeth per
subject. Four hundred twenty-eight of these teeth (44 %) were The prevalence of DH found in this study was 46 %, which is
sensitive when stimulated with the probe and 859 (87 %) were much higher than the 17 % diagnosed in 1992 by Fischer and

Table 1 DH and its relation with

gender and age (n=300, where Presence of DH Gender Age
139 subjects were diagnosed
with DH) female male 18–30 31–60 >60

Yes 100 (56 %) 39 (32 %) 37 (41 %) 69 (51 %) 33 (43 %)

No 79 (44 %) 82 (68 %) 52 (58 %) 65 (49 %) 44 (57 %)
Total 179 121 89 134 77
Odds ratio 2.66 0.76 1.45 0.82
(CI) (1.64–4.31) (0.46–1.25) (0.92–2.30) (0.49–1.39)
Χ2 15.28 0.89 2.23 0.33
p values 0.00009 0.34357 0.13527 0.56395
 Clin Oral Invest

Fig. 1 Odds ratio with 95 %

confidence intervals for DH
and frequency of tooth brushing
(per day). Asterisk (*) imply
significant difference

colleagues [13] in an investigation also performed in Brazil. individual’s oral hygiene habits, mainly toothbrushing,
Although both studies concerned different Brazilian popula- are important factors in the development of DH. Differ-
tions, one from a Dental School and the other from a Marine ent from previous studies [8, 22] that found a peak in
Dental Clinic, it is undeniable that nowadays, individuals are DH prevalence in certain age groups; in this investigation
retaining their natural dentition for a longer period of time in we were not able to observe any association between DH and
their mouths in comparison to past years and, as conse- age.
quence, the deleterious effects of tooth wear are becoming Regarding DH clinical features, it was observed that the
more evident. Thus, this increase in the prevalence of DH left side of the mouth was most frequently affected by DH.
may be a reflection of this fact. Similar to our results, Since it is known that right-handed subjects tend to brush
Liu et al. [14] and Taani and Awartani [15, 24] also more on the left side of the mouth [25], and assuming that
found a high prevalence of DH (ranging from 32 to 53 %) in most of the patients participating in this study were right-
a population from a hospital and from a general practice, handed, it seems that toothbrushing abrasion may indeed be
respectively. Both investigations were also comprised of a an important component in the development of DH [27].
questionnaire and a clinical exam to confirm the presence of Corroborating this concept, in the present study, it was found
DH. that subjects who brush their teeth four times a day, as well as
In agreement with previous investigations [13, 16, 24], subjects who apply excessive force during toothbrushing,
this study showed that women were more at risk for DH than may have more risk for DH. Also concerning toothbrushing,
men. This fact may be related to the observations that DH is we could not find any association between the hardness of
strongly associated with gingival recession and low plaque different brush bristles and DH. Although differences be-
scores and women tend to demonstrate better oral hygiene tween the populations must not be disregarded, this result is
care than men [25, 26]. Thus, it may be suggested that the in contrast with the study of Bamise et al. [12], in which DH

Fig. 2 Odds ratio with 95 % confidence intervals for DH and hardness of brush bristles and DH and brushing with excessive force. Asterisk (*) imply
significant difference
Clin Oral Invest

Fig. 3 Odds ratio with 95 %

confidence intervals for DH
with bruxism, gastroesophageal
reflux, and frequent vomiting.
Asterisk (*) imply significant
difference

was strongly associated with subjects who used hard brush performed with a simplified score system, based on a descrip-
bristles for toothbrushing. tive category scale, since the intention was only to give an
In agreement with most of the DH investigations [12, 13, overview of the degree of sensitivity in that population.
16, 22, 28], cold was reported as the most common pain- Despite not being an exact reproduction of daily life
inducing stimulus. According to the hydrodynamic theory stimuli [14], in this investigation, the evaporative/cold stim-
proposed by Brännström [29], the pain in DH occurs due to a ulus showed to be a better method to detect hypersensitive
stimulation of nociceptors located on the dentin–pulp inter- teeth than the tactile stimulus, as a greater number of teeth
face, as a result of an inward or outward movement of the were sensitive to the air from the syringe in comparison to
fluid within the dentinal tubules. This movement can be the probe. This is in agreement with previous reports on the
caused by tactile, thermal, or chemical stimuli applied to literature [13, 14] and according to Absi et al. [31], it may
the exposed dentin surface. It is speculated that cold stimulus have occurred because usually, only a small area of the
causes a rapid and intense fluid flow away from the pulp, exposed dentin is sensitive, and if the probe did not touch
which will result more often in pain sensation in comparison this area, the subject will probably not respond.
to other stimulus, such as heat [30]. Most subjects described Bruxism and gastroesophageal reflux were also strongly
their pain as just a mild discomfort, but moderate pain was associated with DH. Ommerborn et al. [32] found a higher
also frequently reported. Although the subjects did not con- prevalence of non-carious cervical lesions in subjects with
sider DH a strong pain sensation, 37 % of them felt extreme- bruxism. Since non-carious cervical lesions are also fre-
ly uncomfortable with this sensation and have already quently associated with DH, this could explain the greater
searched for treatment, mainly by the use of desensitizing risk for DH found in this study for subjects with bruxism. It
toothpaste (27 %). Similar findings were also reported by has been well established that gastroesophageal reflux and
Fischer et al. [13], who observed that 32 % of the patients frequent vomiting may cause dental erosion [33], due to the
with DH had tried desensitizing toothpastes as treatment. It contact of the hydrochloric acid with the tooth structure. In
should be pointed out that the pain evaluation in our study was addition, previous investigations have shown that erosive

Fig. 4 Odds ratio with 95 %

confidence intervals for DH
with consumption of acidic
foods and drinks. Asterisk (*)
imply significant difference
 Clin Oral Invest

acids can dissolve the smear layer and open dentin tubules, 10. Gillam DG, Seo HS, Newman HN, Bulman JS (2001) Comparison
of dentine hypersensitivity in selected occidental and oriental pop-
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the consumption of acidic foods and drinks and between DH prevalence and distribution of dentine sensitivity in a population
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Conflict of interest The authors declare that they have no conflict of
studies. Dent Clin N Am 34:531–544
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